- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,168.69
| Professional | | $1,778.28 | $2,344.23 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $2,630.27
| Professional | | $2,089.30 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,388.44
| Facility | | $2,691.53 | $2,951.21 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,388.44
| Professional | | $2,691.53 | $2,951.21 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $2,754.23
| Facility | | $1,513.56 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,621.81 / $3,548.13
| Professional | | $79.43 | $1,621.81 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $4,073.80
| Professional | | $2,398.83 | $2,818.38 | $4,073.80 |